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Radar Supersalud - Episodio 1 Rol como juez y conciliador en los conflictos de salud — Transcript

by Superintendencia Nacional de Salud · 1,978 words · 339 segments · language en · Watch on YouTube

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0:17Hello, thank you for being here on
0:19Radar Supersalud, the video podcast
0:21from the National Superintendency of
0:23Health to resolve your health-related
0:25questions in a clear, simple, and
0:27direct way. We traditionally think that
0:30the Supersalud only sanctions and
0:32monitors, however, it also has the
0:33legal authority to act as a judge and
0:35conciliator to resolve disputes. To
0:37discuss this wonderful institutional
0:39tool, we are joined by Gustavo Adolfo
0:41Flechas Ramírez, Delegate
0:43Superintendent for the Jurisdictional
0:45and Conciliation Function. Welcome,
0:47Delegate Gustavo.
0:49Fernanda, thank you very much, and
0:50thank you to the Radar for this
0:52invitation and for opening these
0:53institutional spaces that allow us to
0:54build bridges with our population.
0:57Thank you very much. Please tell us,
0:59what is the Delegation for the
1:00Jurisdictional and Conciliation
1:01Function of the National
1:02Superintendency, and what is its role?
1:05Organically, it is established as one
1:07of the seven delegations of the
1:09National Superintendency of Health.
1:11This delegation, as you rightly note,
1:13has a jurisdictional function, or
1:15translated, it is responsible for
1:17acting as a health judge. And
1:19additionally, with the no less
1:21important function of conciliation, a
1:23fundamental characteristic to
1:24understand how this delegation works is
1:26that it does not perform inspection,
1:28monitoring, and control duties, as you
1:30noted at the beginning, right? The
1:34National Superintendency of Health not
1:37only sanctions, monitors, and inspects,
1:39but also, by legal mandate and under
1:42the National Constitution, acts as a
1:44judge among the actors of the General
1:47System of Social Security in Health and
1:49fulfills a conciliatory role. For what
1:53purpose? To improve the flow of
1:55resources within the system between the
1:57entities responsible for payment or EPS
1:59, and additionally between service
2:01providers, whether they are hospitals
2:03or private clinics.
2:05To make it simpler and explain it to
2:08our audience, many people assume that
2:10any claim before the entity is the same
2:12, however, there are different paths.
2:15That is correct.
2:16Could you please explain the difference
2:18between filing a PQRD and turning to
2:19the jurisdictional function? That is
2:22important, because look at the complete
2:24function that the National
2:25Superintendency of Health has through
2:27the delegation for the Ombudsman's
2:28office or for the defense and
2:30protection of the user. The DPU is
2:32responsible for channeling, receiving,
2:34managing, providing solutions, giving
2:37prompt and timely responses, and
2:39calling on the EPS to resolve the PQRs,
2:41as you rightly noted. The PQR is a
2:45mechanism that is more expedited, more
2:48accessible to the citizen, and intended
2:50to inform our entity and the EPS,
2:53pharmaceutical manager, or the health
2:56system actor that is failing to meet
2:58its duties regarding some deficiency
3:01they have. The most expeditious
3:05mechanisms are by phone, email, the
3:08Superintendency's website, and
3:10reporting any anomaly within the system
3:13. Unlike the jurisdictional function,
3:18it requires a series of prerequisites
3:21that are not as specific as a lawsuit
3:24in the judicial branch, but do require
3:27meeting minimum requirements to become
3:30a formal claim. In a lawsuit, the EPS,
3:35the pharmaceutical operator, and the
3:37actor in conflict with the system user
3:40are summoned regarding a denial, a
3:42delay, a coverage problem, or an
3:45out-of-pocket health expense the user
3:47should not have incurred, so that we,
3:50through the intervention of the
3:52jurisdiction, aim to resolve their
3:54conflicts with the same authority as a
3:57judge of the Republic. Basically, to
4:01wrap up this topic, PR is the most
4:04expeditious means to report any anomaly
4:07of the user regarding the system, while
4:10the jurisdictional path involves
4:12specific requirements found in Law 1949
4:15, Article 6, which sometimes even
4:17allows for representation by an
4:20attorney.
4:21This sounds very relieving. This is
4:24precisely what interests our audience
4:26the most: the ABCs, the "how," and how
4:28the difference works. So, if a person
4:32identifies with those requirements you
4:34mentioned today and needs your support,
4:36in what cases can a citizen turn to the
4:38Office of the Delegate for
4:40Jurisdictional and Conciliation
4:42Functions, and how should they do it?
4:45Let’s talk a bit about that "how" and
4:46those ABCs.
4:47It’s important, Fernanda, because we
4:50handle three areas. Regarding problems
4:55with coverage in the General System of
4:58Social Security and Health—such as
5:00technologies, medications, procedures,
5:03or specialist appointments not provided
5:06in a timely and effective manner by the
5:09EPS—we intervene so that this lack of
5:11rights guarantee is covered immediately
5:14as a result of our intervention as
5:17judges issuing orders. This
5:21jurisdictional function is so important
5:23that, as I noted, it stems from the
5:25National Constitution, which
5:27establishes that administrative
5:29authorities such as the National
5:30Superintendency of Health may exercise
5:33the functions of a judge. Additionally,
5:36our second instance is the higher
5:38tribunals in the labor chamber, which
5:40provides, for example, the principle of
5:43the second instance. And let's go back
5:46to the ABCs you correctly noted,
5:48Fernanda, which are coverage problems.
5:50Economic recognition. This financial
5:53reimbursement exists because sometimes
5:56we, a family member, an acquaintance,
5:58or even ourselves, have to incur what
6:00are called out-of-pocket expenses: if
6:03you don’t have the medication on time
6:05, if you don’t have the procedure on
6:07time, or if you don’t get a
6:09specialist appointment promptly, you
6:11end up covering those costs from your
6:14own pocket. This may alleviate your
6:17health problem, but it creates an
6:20expense that is illegal. Therefore, by
6:23virtue of this, we intervene. And if it
6:27can be substantiated summarily—that
6:30is, in a very simple way—by proving
6:33coverage, proving the lack or absence
6:36of that technology, procedure, or
6:39specialist appointment, and also
6:42proving the expense incurred, which is
6:45documented by an invoice, we then take
6:48that evidence, issue a ruling, and
6:53immediately order the EPS to reimburse
6:56the money to the system user or patient
6:58who incurred that expense. I repeat and
7:02insist, an unjustified expense.
7:05Now that you mention saving time and
7:07money, let’s also talk about an
7:09important type of savings: avoiding
7:11emotional strain. And for this,
7:14conciliation draws our attention. Yes.
7:17How does conciliation contribute to
7:19resolving conflicts between actors in
7:20the healthcare system?
7:22Well, here, conciliation is part of—
7:24and I will also refer back to the
7:26organizational structure of the
7:28delegation, which is the delegate's
7:30office and the two directorates, one
7:32for jurisdictional matters and the
7:34other for conciliation. Looking at the
7:37scope of the conciliation directorate,
7:40it is a function that has been
7:41established for over 15 years within
7:43the National Superintendency of Health.
7:47Unlike the jurisdictional function,
7:49which comes from a regulatory
7:51development since 2019, conciliation
7:53allows actors in the system—but in
7:55this case, qualified actors such as the
7:58EPS or those responsible for health
8:00service payment, and additionally state
8:02social enterprises, accredited clinics,
8:05and enabled providers—where it is no
8:07secret that there is a problem with the
8:09flow of resources within the system due
8:12to the non-timely payment of invoices.
8:16by the EPS. There are also problems
8:20with billing disputes, returns, and
8:22other phenomena associated with
8:24invoicing that prevent the flow of
8:26resources and the billing submitted by
8:29hospitals and clinics to the EPS from
8:32flowing in the way we need. It is
8:36important to highlight that we are not
8:39here judging, preventing, or
8:41sanctioning any of the actors, neither
8:44the payer nor the state social
8:46enterprise or the IPS waiting for
8:48payment for those services via
8:50invoicing. What do we do? We have our
8:55doors open at the delegate office and
8:57the conciliation directorate so that,
8:59in a very calm and simple way, you can
9:02come to conciliation. We call the EPS,
9:07we call the IPS or the state social
9:09enterprise; they sit down, put their
9:12cards on the table, look at their
9:15accounts, and we, as friendly mediators
9:18also vested with authority (which is
9:21the regulatory framework for
9:23conciliation), pave the way, I repeat,
9:26so that these accounts can be settled.
9:31Conciliation agreements have a very
9:33important characteristic, which is the
9:35disposal of rights by both parties. We
9:39are there as guarantors that the rules
9:41on contracting, billing, and
9:43obligations are clear, express, liquid,
9:46and enforceable, are taken within the
9:48legal framework, and that resources
9:51flow and friendly agreements are
9:53reached, but they must originate from
9:56each of the entities. We are friendly
10:00mediators, but additionally, when a
10:02conciliation process is concluded, a
10:05document is issued with all legal
10:07backing that contains obligations that
10:10are mandatory, redundant as it may seem
10:12, for the parties. That is to say, the
10:16IPS that reported a billing and
10:18presented it to the company responsible
10:20for payment and insurance, and the
10:22latter pays the obligations according
10:25to what was recorded. What happens with
10:27this? It is recorded in minutes that
10:30have special characteristics, which
10:32provide executive merit and become res
10:35judicata. Executive merit means that
10:37with the conciliation minutes, you can
10:39initiate an executive process before
10:41the ordinary jurisdiction without
10:43having to bring the pile of invoices
10:45that led you to this conciliation. What
10:48this makes clear to us, Fernanda, is
10:50that this conciliation mechanism is one
10:53in which the system's actors are
10:55placing their trust. If we were to make
10:59a call and the turnout were not as
11:01favorable as what we are reporting
11:03today, we would have to change course
11:05and say that something is failing. But
11:09the number of citations shows that
11:11conciliation among the system's actors
11:14is a mechanism, and most importantly,
11:16that the citizen, the providers, and
11:19the EPSs trust the National
11:21Superintendence of Health as the
11:23governing body of the system. And as a
11:28guarantor of the rights of one and the
11:30other.
11:31Thank you very much, Doctor, for
11:32explaining all this behind-the-scenes
11:34work that guarantees the fundamental
11:35right to health. To clarify things a
11:38bit more for our audience, could you
11:40please explain what "glosas" are?
11:43Well, this is part of the
11:44jurisdictional function in the three
11:46areas it covers: coverage, financial
11:49recognition, and glosas. Glosas are a
11:51phenomenon that occurs between the
11:52healthcare provider—hospitals and
11:54clinics—and the health insurance
11:55company, or EPS. The party responsible
11:57for payment. When the service provider
11:59—the hospital—submits a bill to the
12:02EPS, the EPS can take one of two paths:
12:05pay the total invoice or issue a series
12:08of glosas. Basically, so the citizens
12:11can understand, it means if 10 pesos
12:13are billed, I’ll say: "No, I need you
12:16to clarify four pesos from these
12:18clinical labs, for example; I’ll pay
12:21you six, and I still owe you four," and
12:23that’s where those four pesos get
12:26stuck. Despite being within the system
12:29—despite in what sense? Despite its
12:30negative value, because it’s money
12:32that neither leaves one place nor
12:33arrives at the other. What happens when
12:35people cannot reach an agreement, or
12:37rather, these institutions cannot reach
12:38an agreement? They come to the third
12:41party, which is us at the National
12:43Superintendency of Health, and say: "
12:45Look, we couldn't reach an agreement
12:46regarding this glosa for clinical labs,
12:48procedures, hospital stays, and so on."
12:52We have a duly qualified technical
12:54assistance group that will resolve that
12:57conflict between the two, and in this
12:59way, the flow of resources between them
13:01is also improved. So, when they come to
13:05us regarding glosas, they also file a
13:07claim, and we resolve the conflict—we
13:10settle it. We issue an order declaring
13:12that this must be paid and that this
13:14was not supported. The person, or the
13:17clinic, or the company responsible for
13:19payment can challenge our ruling in
13:22labor court, and that is extremely
13:24important because the actors in the
13:26system will start to understand that
13:29this glosa process is very draining.
13:32Sometimes a bad practice in healthcare
13:34is created that is focused—perhaps,
13:37sometimes, and we cannot generalize—
13:39on the flow of resources not being as
13:42expected within the system. Of course,
13:45and this affects the general health
13:47system and the fundamental right to
13:49health. Thank you all for tuning in to
13:52this episode of Radar Supersalud, and
13:53remember that knowing your rights is
13:55the first step toward defending them.
13:57See you soon.

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